INTRODUCTION:

“BE ALERT NOT ALARMED”

In the early nineties when revolution was occurring in health care system throughout

the world, India was facing a lot of deaths due to communicable diseases. However after

independence, the Government of India took lot of measures to improve the life expectancy

of Indian population, these measures gave fruitful results by showing a massive control in

mortality due to communicable diseases. World Health Report (1999) gives the main causes

of mortality in India as non-communicable diseases (48 %), communicable diseases (42 %)

and injuries (10 %).1 This revealed the decrease in death rate and the better improvement of

quantity and quality health services in India. A report from united nation world population

prospects indicated a shift in demographic profile from 45 years in 1971 to 64 years in

2005-2010. It is estimated that life expectancy of the Indian population will increase to 70

years by 2021–25. In modern era where urbanization, industrialization, life style changes

and population growth etc are influencing the disease pattern, we can see a paradigm shift

from communicable disease to non-communicable diseases like cancer, diabetes and

hypertension. Recent times have seen an increase in the incidence of cancer.2

Cancer prevalence in India is estimated to be around 2.5 million, with over 8,00,000

new cases and 5,50,000 deaths occurring each year due to this disease. 3 The last fifty years

have seen an exploration in our understanding of this most fundamental of diseases, and

new discoveries are occurring on an almost weekly basis. A trend analysis of the data on

cancer incidence for the period 1975-2008 has demonstrated that the overall occurrence of

1
cancer is increasing among females. The greatest increase among females was for cancer of

the cervix and breast.4

Cervical cancer is a devastating disease for women around the world. Nearly

500,000 women suffer from the disease and more than 270,000 die each year. Globally,

cervical cancer is the second-most-common cancer among women. It is the leading cause

of female cancer deaths in developing countries, where 80% of cervical cancer cases and

deaths occur. Tragically, this disease strikes women at a relatively young age. Many victims

of cervical cancer die in their early 40s, while they are still contributing to the workforce

and raising children. Over the past 50 years, many developed nations have achieved

success in reducing cervical cancer by routinely screening women with Pap tests. Despite

this progress, even in countries with well-established screening programs, many women

continue to suffer and die from cervical cancer. The situation is direr in developing

countries, many of which lack an infrastructure for cervical cancer screening and treatment.

In these countries, most cases of cervical cancer are undetected, resulting in hundreds of

thousands of deaths every year.

Without a widespread and sustainable commitment to mobilize change, projections are

that 700,000 cases of cervical cancer will occur worldwide in 2020, a 40% increase from

the number of cases in 2002. Over the past decade, dedicated scientists, researchers,

clinicians, frontline health workers, community leaders and advocates have worked

tirelessly to bring the scourge of cervical cancer to the world’s attention and to develop and

apply the necessary knowledge and technologies to reduce the number one cancer killer of

women in most developing countries. From Mumbai to Mexico City, Kampala to

2
Kathmandu, innovative programs have learned how to successfully deliver effective

cervical cancer prevention programs to the women and girls who need them most.5

The pap smear is a primary diagnostic tool for cervical cancer. 1 A pap smear is taken

for early detection of cervical cancer and diagnosis of precancerous and cancerous

condition of the vulva and vagina.2 The inventor of the pap smear is George Nicolas

Papaniclolauo. In 1939 the re-evaluation of the vaginal smear for cancer detection began,

at New York Hospital, all women patients were required to take a routine vaginal smear.

Dr.Herbert Traut, a gynaecological pathologist, collaborated with Dr. Papanicolauo to

validate the diagnostic potential of the vaginal smear. In 1943, they published their

findings and conclusion in the famous monograph, “Diagnosis of uterine cancer by the

vaginal smear”. The diagnostic procedure was named the “pap test”.3

A Pap test should be performed during the second half of the menstrual cycle (Day

14). Sample collection usually begins with appropriate instruction to the patient. Patients

must abstain from sexual intercourse and avoid using any vaginal medication or

contraceptives 48 hour before sample collection. The patient is placed in lithotomy

position and the cervix is visualized by means of a speculum. The smaller end of the

Ayer’s spatula is introduced through the external Os and the squamocolumnar junctions

are scraped by rotating the spatula to 360°. The scraping is the evenly spread onto a glass

slide, which is immediately fixed using 95% ethyl alcohol and ether or a cyto spray to

avoid air drying artifacts.4

Primary prevention of cervical cancer focuses at modifying the avoidable risks to

reduce women’s chances of getting cervical cancer. The main strategies are organized

programmes to promote safer sex, anti-smoking, regular pap smear test and healthy diet.5

3
 With regular screening tests and follow-up cervical cancer can be prevented. Two

screening tests can help prevent cervical cancer or diagnose it early. The Pap Smear test

looks for precancerous, cell changes on the cervix that might become cervical cancer if

they are not treated appropriately, the HPV test looks for the virus (human papilloma

virus) that can cause these cell changes.6

Human papilloma virus infection is the main and necessary virus for this cancer. It is

a sexually transmitted virus passed through genital contact. Early marriage, use of oral

contraceptives, consumption of tobacco, smoking, immune suppression, infection through

other sexually transmitted diseases and poor nutrition have been associated with the

development of cervical cancer.7

High-risk regions are Eastern and Western Africa (ASR greater then 30 per

100,000), Southern Africa (26.8 per 100,000), South-Central Asia (24.6 per 100,000),

South America and Middle Africa (ASRs 23.9 and 23.0 per 100,000 respectively). Rates

are lowest in Western Asia, Northern America and Australia/New Zealand (ASRs less than

6 per 100, 000). Cervical cancer remains the most common cancer in women only in

Eastern Africa, South-Central Asia and Melanesia. Between 1955 and 1992, cervical cancer

mortality in the United States declined by nearly 70% and rates continue to drop by about

3% each year. In low- and middle-income countries, similar success has not yet been

achieved. The disease continues to grow, fanned by gains in life expectancy and population

growth. By 2030, cervical cancer is expected to kill over 474,000 women per year and over

95% of these deaths are expected to be in low- and middle-income countries. India has a

population of 366.58millions women ages 18 years and older who are at risk of developing

4
cervical cancer. Current estimates indicate that every year 134420 women are diagnosed

with cervical cancer and 72825 die from the disease.6

This shows that in spite of lot s of effort put by health care sector still there is lack

of knowledge and awareness regarding cervical cancer among women in our country. This

outlook provoked me to take a glance in our society’s female awareness and attitude

regarding cervical cancer and what all measures can be implemented to shake the hands

with the experts who are constantly lending their support and encouragement to have a

women world without cervical cancer.

NEED FOR STUDY

“You'll come to learn a great deal if you study the Insignificant in depth”

One out of every five women in the world suffering from this disease belongs to

India. It is estimated that there were 112,609 new Cervical Cancers in 2004 and this

number is expected to rise to 139,864 in 2015 10. Cervical cancer ranks as the 1st most

frequent cancer among women in India, and the 1st most frequent cancer among women

between 18 and 44 years of age. About 7.9% of women in the general population are

estimated to harbour cervical HPV infection at a given time, and 82.5% of invasive

cervical cancers are attributed to HPVs.7

A study conducted by the New England Journal of Medicine reveals that about 1.3

lakh new cases of cervical cancer are reported every year, in India and about a quarter of

the five lakh cases globally. Experts point out that women need to be sensitised to curb

the growth of this disease. “Even the educated class are not aware of cervical cancer and

5
often link it with the neck. We have to explain to them that cervical cancer is caused in

the lower part of the body," says gynaecologist, Sunita Verma. Cancer Research

Foundation of India (CRFI), a recently constituted body is actively involved in spreading

awareness. Dr Siddharth Sahni, co-founder, CRFI says, "Awareness, prevention and

detection is what we are striving for to deal with cancer. We need to reach out to both

grass roots and urban India".

Cancer of the cervix has been the most important cancer in women in India over the

past two decades. It accounted for 16 per cent of all cancers in women in the urban

registries in 2005. Over 70 per cent of the Indian population resides in rural areas;

cervical cancer still constitutes the number one cancer among females. In the hospital

based cancer registries (HBCRs), the leading site for cervical cancer is Bangalore and

Chennai, the second leading site in Mumbai and Thiruvananthapuram and the third

leading site in Dibrugarh. The percentage of cervical cancer constitutes 11.4% in

Thiruvananthapuram, 30.7% in Chennai, 40% in Bangalore respectively. In spite of

having had a diagnosis of cervical cancer in Chennai, Trivandrum and Bangalore it has

been reported that they didn’t receive active treatment9. More than three-fourths of these

patients are diagnosed at advanced stages leading to poor prospects of long-term survival

and cure, despite of health care institutions efforts in introducing lot of screening

programs. Incidences has not decreased especially among poor, rural women, who make

up the majority of cervical cancer victims due to lack of awareness, knowledge,

inaccessibility to screening and cultural barriers.8

Indian government has introduced a variety of a national health programs and screening

camps in various states in order to fight against the rising numbers of incidence and

6
 mortality among women due to cervical cancer. In spite of all these measures the no of

incidences are not coming down rather increasing hence the researcher felt that there is an

eminent need to find out, the women, in selected community posses what level of

understanding about this dreadful disease and how necessary it is to provide information

regarding cancer of cervix and its prevention to women. Hence researcher interested to

assess the knowledge regarding cervical cancer reproductive age group women.

There is a need to promote pap smear test among women by informing them on their

susceptibility to cervical cancer and encouraging a belief that active and regular pap smear

test can detect cervical cancer at the pre-cancerous stage, hence enabling the early

treatment and prevention of cancer development. There is also a need for provision of

affordable screening services all over the country to enable women, after being motivated,

to go for screening.12

The researcher during her clinical exposure came across women who lacked

knowledge regarding Pap smear test and its importance in prevention and detection of

cervical cancer. Hence the researcher felt a great need to assess the knowledge of women in

the age group of 18 to 55 years, since they are the vulnerable group and also educate them

regarding the importance of pap smear test

REVIEW OF LITERATURE:

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 The purpose of review of literature is to obtain comprehensive knowledge base and in

depth information from previous studies.

A review of literature is an essential aspect of scientific research .it helps the investigators

to establish support for the need for the study, select research design, developing tools

and data collection technique the review of literatures is classified under following

headings.

1. Studies related to knowledge and attitude

2. Studies related to awareness and prevention

3. Studies related to barriers of cervical screening.

Studies related to knowledge and attitude

A study was conducted to examine knowledge regarding cervical cancer among

400 female workforces in U.K by using knowledge questionnaire on cervical screening

treatment for abnormalities and HPV. Four Hundred women returned completed

knowledge questionnaires of cervical cancer were good but risk factors for cervical

cancer were not well known. Awareness and knowledge of HPV was very limited. It is

essential to improve women’s knowledge of cervical cancer and risk factors. 9

An exploratory study was conducted in Australia among 140 females from Sydney

University regarding social and psychological impact of HPV in cervical screening among

females aged 18-45 years (mean 19yrs, SD 3.3yrs) using purposive sampling. The results

were revealed as 25.7% of students reported “having ever heard of HPV”, compared to the

89.3% who reported “having ever heard of genital warts”. When asked whether HPV

8
infection is the main cause of cervical cancer, 11.6% said yes, 5.8% said no, and 82.6%

said they didn’t know. The study was concluded with saying that there is low awareness of

HPV per se and low awareness of the link between HPV and cervical cancer.10

A survey was conducted in Queen Victoria hospital in Australia to understand

women’s current knowledge, attitudes and behaviours related to HPV, the HPV vaccine,

cervical screening and cervical cancer. A sample of 1000 women was surveyed via

telephone plus five focus groups (young, older, Iraqi, TAFE, nurses). the results concluded

with a view that all participants were having positive attitude about cervical screening and

the vaccine.10

An exploratory research design was adopted to assess the knowledge and practice

regarding cervical cancer among 100 married women between the ages 20 -60 years at

Indore (M.P) using purposive sampling. The investigator used a structured questionnaire of

9 items to assess the knowledge regarding early diagnosis and prevention of cervical

cancer. Reliability was calculated using split half method and the 'r' value was 0.8. The

findings revealed that all of the subjects 100(100%) had no knowledge regarding early

diagnosis and prevention of cervical cancer, 86(86%) of the subjects were at low risk for

cervical cancer, 14(14%) of them are at moderate risk for developing cervical cancer.

Hence the conclusion was made by saying that there is a need to create public awareness

regarding the benefits provided by the government through various health schemes and all

government hospitals must make these schemes available to the population. Nurses should

also be trained through in-service education to spread the health awareness to the

individuals and families. 11

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 A study was conducted to evaluate the knowledge and attitudes of women about pap

smear testing among 332 married women in Turkey. Data was collected through printed

questionnaire. The result revealed that over 90% of the study group had never heard of and

had not undergone Pap smear screening before. Of the 332 smears evaluated, 328 (98.8%)

were accepted as normal, whereas epithelial cell anomalies were seen in 4 (1.2%), infection

in 59 (17.7%), and reactive cell differences in 223 (67.2%) of the smears. The researcher

concluded that the knowledge regarding Pap smear screening was 10% and suggested Pap

smears can be easily taken and evaluated through a chain built between the primary health

care unit and laboratory, and this kind of screening intervention is easily accepted by the

population served.13

A descriptive study was conducted to determine the knowledge and the status of the

pap smear test among the nurse/midwives working in the gynaecologic / obstetric clinics of

three big hospitals located in the central city of Ankara. The data collected through

questionnaire were evaluated by means of the package software SPSS as well as decimal

number and Chi-square tests. The study revealed that the nurse/midwives had not enough

knowledge on PST, of whom 58.1% had got no PST, while a portion of 71.5%of those who

had already underwent a PST failed in getting regular tests, and a portion of 73.5% had got

noon-job training on the gynaecological cancers, and a portion of 66.7% of the trained ones

had not any knowledge in respect of PST. It was determined that there was a significant

statistical difference in the level of knowledge on PST in terms of on-job training in respect

of the gynaecological cancers and the PST history (p<0.05).14

A study was conducted in Delhi on the awareness level and usage of pap smear

among medical personnel. Data was collected using a structured questionnaire and data

10
analysed using Epi info software package. The results showed that the level of awareness

about Pap smear was poor among nurses (33%), graduate medical students (35.4%) and

post graduate residents (24.2%). A very low usage of Pap test in the sample group (19.7%)

was revealed. 58.5 % of the respondents answered that it’s not the ideal time to get the test

done though they fall in the eligible age group. Only (44%) of the medicos have ever asked

their family members to get the test done. The study concluded that the awareness and

usage of Pap smear among medical personnel was very low. Thus the researcher strongly

suggested the need for starting awareness campaigns and training programmes for medical

personnel regarding the pap smear test.15

A study was conducted, to determine the knowledge, attitude and practice related

to prevention of cervical cancer among (205) female health workers. The study report

showed that doctors had high level of knowledge, surprisingly inadequate among the

nurses, predictably low among hospital maids. However 93.2% of respondents have

never had pap smear performed. The poor utilization of the test was independent of

respondent’s profession, marital status and hospital. The study was concluded with the

saying that there is a need to intensify campaign towards prevention of cervical cancer

even among health workers11.

A clinical survey was conducted to assess the knowledge, attitudes, and

assumption of cervical cancer by women living in Maroua, the capital of the Far North

Province of Cameroon. It was a single center study. In a 1-month period, 171 women

were surveyed as to their socioeconomic status, sexual habits, prior knowledge of

11
 cervical cancer, its prevention, and their attitudes toward cervical cancer. Of 171

women, 48 (28%) had prior knowledge of cervical cancer; they were classified as the

"aware group" compared with 123 of 171 (72%) women who were uninformed about

cervical cancer and they were classified as the "unaware group" (UG). The UG of

women tended to be single mothers, illiterate, housewives, and had their first child

before the age of 20 (p < 0.005). Despite the awareness of cervical cancer by 28% of

women, only a minority of them, 4 of 48 (8.3%), underwent a preventative screening

test. Only 71 of 171 (41.5%) women stated that they would be having a screening test

in the future. The awareness of cervical cancer by women in Cameroon is still

inadequate. Thus they concluded that, to avoid deaths from cervical cancer, a curable

and preventable disease, the need of an aggressive campaign to make Cameroonian

women aware of cervical cancer and its prevention is needed12.

A study was conducted among young women in Australia to examine their

attitude related to Pap tests including HPV. A convenient sampling method was used on 57

female. Out of them, five groups were with women aged 15 to 23 years, and five with

women aged 25 to 44 years. The result says that women of all ages lacked knowledge about

HPV and its association with cervical cancer. The study was concluded with the fact that all

ages lacked knowledge of HPV and its connection to cervical cancer, which could be

targeted in educational campaign13

A cross-sectional, interview- based survey was conducted in three major

teaching hospitals in Karachi regarding knowledge and awareness about cervical cancer

among 400 female interns and nursing staff. Convenience sampling was applied using

12
 questionnaire method. Of all the interviews conducted, 1.8% did not know cervical

cancer as a disease, 23.3% of the respondents were aware that cervical cancer is the most

common cause of gynaecological cancers and 26% knew it is second in rank in mortality.

78% percent were aware that infection is the most common cause of cervical cancer, of

these 62% said that virus is the cause and 61% of the respondents knew that the virus is

Human Papilloma Virus (HPV). Majority recognized that it is sexually transmitted but

only a minority (41%) knew that it can be detected by PCR. Only 26% of the study

population was aware of one or more risk factors. This study serves to highlight that the

majority of working health professionals are not adequately equipped with knowledge

concerning cervical cancer. Continuing Medical Education program should be started at

the hospital level along with conferences to spread knowledge.14

A study conducted to determine the effectiveness of self instructional modules

on knowledge of women regarding cervical cancer, its detection and control in Pune city.

Evaluative approach was used with Quasi-experimental pre-test post-test design. The

women in the first group were given a pamphlet and the women in the second group were

given a self-instructional module. The findings of the study revealed that women in both

group gained significantly in the post-test. For group one “t” value obtained was 10.27 and

for group two, “t” value obtained was 8.60.The researcher concluded that the use of both

self instructional modules were effective in gaining knowledge regarding cancer of cervix.15

A study was conducted on the role of risk factors in cervical carcinogenesis and

strategies for control of the disease have been assessed from the accumulated cytological

data, derived from 35years of hospital –based screening in Lucknow, North India .A total

13
of 36,484 women have been cytological screened during a span of 35years in the

gynaecology OPD of Queen Mary’s Hospital. The frequency of SIL (Squamous

Intraepithelial Lesion) and carcinoma was found to be 7.2% and0 .6%; the study revealed

high age >40(1.3%) and parity 3 and above(0.9%) as a predominant factor in cervical

carcinogenesis. The study also emphasized great value of clinically down staging the

cervical cancer by detecting cervical cancer in the early stage. The study also revealed a

significant difference in the frequency of SIL in symptomatic (1.7%) and asymptomatic

(0.08%) women. Based on the analyzed data researcher concluded that single lifetime

screening which appears to be the most feasible and affordable mode for control of

carcinoma cervix in developing countries like India16.

A cross sectional survey among women greater than 18 yr attending Mahalapye

District Hospital in Botswana was conducted in which a questionnaire was used to

interview 300 participants in order to assess their perceived susceptibility to cervical

cancer, their perceived severity of cervical cancer, their perceived benefits of doing cervical

cancer screening and their perceived barriers of seeking cervical cancer screening. The

result showed that Cervical cancer screening rates was 39%. Participants were aware of the

perceived severity of cervical cancer (average response 2.58-3.60), perceived benefits of

cervical cancer 6 screening (average response 3.10-4.33) and perceived barriers to seeking

cervical cancer screening (average response 2.0-3.44) but these were not significantly

associated with screening. The highest predictor of cervical cancer screening was perceived

susceptibility and those with high perceived susceptibility were 3.2 times more likely to do

cervical cancer screening than those with low perceived susceptibility. Main socio-

14
demographic characteristics significantly associated with perceived susceptibility were

employment, monthly income and residential area while perceived severity was

significantly associated with monthly income and residential area17

Studies related to awareness and prevention

A study was conducted to Test knowledge of HPV, cervix cancer awareness and

acceptance of HPV vaccination of women now and a year ago among 305 women visiting

regional Hospital Heilig Hart, Tienen, Belgium during two subsequent weeks using

questionnaire method and the result showed Knowledge about HPV as a cause of cervix

cancer and the presence of a vaccine rose from roughly 50% in 2007 to over 80% in 2008

(p < 0.0001). Level of education and having daughters, sons’ or no children no longer

influenced the level of knowledge or willingness to accept the vaccine. Most parents favour

the age group 12–16 years as an ideal time for vaccination. In contrast with the 2007survey,

women below 26 years had now acquired almost equivalent knowledge to older women

about the virus, cervix cancer and the vaccine, but they were far less likely to accept the

vaccine due to its cost, unless it would be reimbursed.18

A study was conducted on awareness if cervical cancer – a case control study on

north Indian population. The present case control study on married women with cervical

cancer and controls ( 100 each) revealed the association of age at marriage, socioeconomic

status and parity with cervical cancer but young age at marriage (rr 3.79) and low

socioeconomic status (rr-3.81) emerged as independent predictor of disease status.19

The study was conducted to assess the number of women taking part in the secondary

prevention of cervical cancer. The results of four cervical prevention surveys on

15
representative samples of polish women aged over 35 years were compared 58% of women

have awareness of cytological test. 12% of women have yearly visits of cytological test,

cytological test done during last three year by 7%. The lowest level of awareness and the

lowest frequency of using prevention service were declared among women aged over 60,

represented the lowest education level. It is important to continue educational work and

intervention measure concerning cervical cancer prevention.20

A Study was done on knowledge and awareness regarding cervical cancer screening

and prevention. The study design followed cohort study (n=529) results low health literacy

(<9th grade) was found among 40% of participants minority women were know about pap

test (9% vs 21%;P<.0.3) and were significantly more likely to have low literacy level

compared with white women (46% vs 15%; p<0.05) literacy was the only factor

independently associated with knowledge related to cervical cancer screening and

prevention. Finding improved awareness, development of screening, and prevention

regarding cervical cancer21. .

Studies related to barriers of cervical screening.

A study was conducted to identify the barriers to cervical screening, about factors

that may influence screening. Among 97 rural women the aged between 16-66 years and

found that 52% had not received a pap smear within the last two years, 42% had never

received a pap smear. The most frequent reason for not obtaining a Pap smear was anxiety

regarding physical privacy (50%), lack of knowledge (18%) and difficulty accessing health

care (14%) women who had delivered children were significantly more likely to have

received a Pap smear (71%), P<0.05. The responses of many women suggests that

16
compliance will cervical cancer screening would be enhanced by addressing cultural

beliefs, encouraging conversation about women’s health issues and increasing the number

of female health care providers. An article explores the negative attitudes some women

have towards the cervical screening programme. These attitudes could ultimately prevent

them from participating in the programme. The native experiences of women who receive a

positive result are also explored. Women’s negative attitudes towards cervical screening

can largely be countered by improving their understanding of the process and diagnosis of

cervical cancer. Women who received a positive smear should be offered support to reduce

their anxiety.

A population-based study was done to find out reasons for women who did not

want to find out reasons for cervical cancer on 430 non-attenders and 514 at tenders of Pap

smear. Report showed, non attendance was positively associated with non use of oral

contraceptive pills, seeing different gynecologists, seeing physicians very often, frequent

use of condom, living in rural or semi rural areas and not knowing the screening test. Socio

economic status and time was not their nonattendance. Another study was done to identify

knowledge, barriers and motivators related to cervical cancer screening with 102 women.

Findings revealed that there was misinformation and lack of knowledge about cervical

cancer. The women therefore confused about the causative factors and preventive strategies

related to cervical cancer. The major structural barriers were economic and time factors

along with language problems. The main psychological barriers were fear, fatalism,

confusion thinking and denial. The barriers to women’s use of cervical screening services

were identified with in 20 women. The study found a high level of awareness of a local

17
cervical screening programme. The specific barriers determined were social problems,

embarrassment, belief in the sacred nature of human sexuality, an anxiety about lack of

confidentiality within small community groups and perceived relationship between cervical

smear and sexual activity.

STATEMENT OF PROBLEM

A study to assess the knowledge and perceived barriers of cervical cancer screening

among women in selected areas of Mysore District.

OBJECTIVES OF THE STUDY:

1. To assess the knowledge of women regarding cervical cancer.

2. To find out the perceived barriers of cervical cancer screening among women
3. To find out the association between knowledge of women with demographic

variables.

18
 OPERATIONAL DEFINITIONS:

 Assessment: It refers to the measurement of knowledge of reproductive age group

women regarding cervical cancer.

 Knowledge: It refers to the level of awareness of information regarding cervical cancer.
 Cervical cancer: Refers to Cancer of cervix, which is a part of female reproductive

system.
 Screening : In this study it refers to Pap smear test for detection and prevention of

cervical cancer
 Women: In this study, woman refers to females between the age group of 19-55 years

HYPOTHESES:

H1:. There will be a significant association between the knowledge of women with their

personal variables

ASSUMPTION:

1. Women have less knowledge regarding cervical cancer.

2. The knowledge level of women will be different.

3. Women may have some knowledge regarding pap smear test.

4. Gaining knowledge on pap smear test may motivate the women for a better practice.

DELIMITATION:

1. Study is delimited to married women between age group between 19 to 55 years

19
 2. Given study, assessed only through structured interview schedule.

RESEARCH APPROACH

The research design selected for this study is Descriptive exploratory survey approach.

VARIABLES

The variables of the study were:

Research variables: knowledge of women regarding cervical cancer, perceived

barriers of cervical cancer screening

Personal variables: Personal variables included were age, education, religion, income,

marital status, number of children, occupation, age at menarche, and previous exposure to

any educational program regarding birth spacing.

SETTING OF THE STUDY

The study was conducted in selected rural areas of Mysore district (Bamboo

bazar).

POPULATION

The population refers to the entire group of persons or subjects that is having

some common characteristics. In the present study women who are in the age group

20
between 19 to 55 years and residing in a selected urban areas of Mysore comprised the

population.

SAMPLE AND SAMPLE SIZE

A sample is a subset of population, selected to participate in a study19. The sample of

present study comprised of married women who are in the age group of 19 to 55 years

residing in selected urban areas of Mysore district. In the present study, two hundred (60)

samples were selected.

SAMPLING TECHNIQUE

Non-probability purposive sampling technique was used to select the samples for the

study.

CRITERIA FOR SAMPLE COLLECTION:

The study will be conducted based on following criteria regarding the selection of

sample.

INCLUSION CRITERIA:

Women who are:

1. Between age group of 19- 55 years
2. Available during the period of data collection
3. Willing to participate in the study

EXCLUSION CRITERIA

21
1. Females less than 19 years and more than 55 years.
2. Females who had undergone hysterectomy surgery.
3. Females who are not willing to participate in the study.

INSTRUMENTS USED FOR THE STUDY

Selection and development of data collection tools

Based on the review of literature the following tools were decided to be developed:

 Structured interview schedule to assess the knowledge of cervical cancer and

perceived barriers of cervical cancer screening among women.

PLAN OF DATA ANALYSIS

Data analysis is the systematic organization and synthesis of research data and

testing of research hypotheses using those data. Data obtained was planned to be coded

and edited to reduce the large data into a master sheet. Both descriptive and inferential

statistics were planned to be used in this study.

a) Descriptive statistics:

 Frequency and percentage would be computed for analyzing the selected

personal variables.

22
  Mean, median and standard deviation would be computed to describe and

compare the determinants of birth spacing among married women,

b) Inferential statistics

 Chi-square would be used to determine association between knowledge of

cervical cancer among women with their selected personal variable.

RESULTS

Analysis is the process of organizing and synthesizing the data so as to answer research

questions and test hypotheses.

This chapter deals with the analysis and interpretation of the data collected to to

assess the knowledge and perceived barriers of cervical cancer screening among women

in selected areas of Mysore District. The data were analyzed on the basis of the study

objectives, using both descriptive and inferential statistics.

The objectives of the study were:

1. To assess the knowledge of women regarding cervical cancer.

2. To find out the perceived barriers of cervical cancer screening among women
3. To find out the association between knowledge of women with their selected

personal variables

23
HYPOTHESES

The hypotheses of the study were:

H1:. There will be a significant association between the knowledge of women with their

selected personal variables

ORGANIZATION OF FINDINGS

The findings of the study are organized in terms of the objectives and hypotheses

tested and are presented in III sections:

Section 1: Description of selected personal variables

1. Frequency and percentage of distribution of married women according to

their selected personal variables.

Section II: Extent of perceived barriers of cervical cancer screening among women

Section III: Association of determinants influencing birth spacing with their selected

personal variables.

24
 SECTION I

DESCRIPTION OF SELECTED PERSONAL VARIABLES

The study consists of 60 samples. The selected personal variables are described

and analyzed under sub headings of the age, religion, education, spouse education,

occupation, income, age at marriage, age of menarche, number of children, type of family

and exposure to any other education program as shown in Table 1.

TABLE 1

Frequency and percentage of distribution of samples according to selected personal

variables

n = 200

Selected personal variables f Percentage

(%)
1. Age (in years)
 19-28 12 20%
 29-37 24 40%
 38-46 15 25%

25
  47-55 09 15%

2. Religion
 Hindu 49 81.67%
 Muslim 05 8.33%
 Christian 04 6.67%
 Any other 02 3.33%

3. Education
 No formal education 20 33.33%
 Primary school education 13 21.67%
 High school education 13 21.67%
 PUC and above 14 23.33%
4. Occupation
 House wife 26 43.33%
 Coolie 22 36.67%
 Employee 12 20%
5. Family income per month
 ≤5000 17 28.33%
 5001-10000 24 40%
 >10000 19 31.67%

6. Age at menarche

 13 9 15%
 14 33 55%
 15 18 30%

7. Age at marriage
 Below 20 years 29 48.33%
 21-25 years 23 38.33%
 Above 25 years 8 13.33%

8. Number of children
 One 8 10%
 Two 36 60%
 Three and above 14 23.33%
 No children 2 3.33%

26
 9. Family history of cervical cancer
 Yes 1 1.67%
 No 59 98.33%

10. Do you know about cervical cancer

 Yes 17 28.33%
 No 43 71.67%

Source of information
 Electronic media 8 47.05%
 Family members 1 5.88%
 Friends 1 5.88%
 Health personal 3 17.65%
 Print materials 4 23.53%

AGE:

The data presented in Table1 and Figure 1 shows that the majority of the respondents
24(40%) belong to the age group 29-37 and the least number 9 (15%) of respondents is
from the age group 45-55.

27
 Figure 1: Frequency and percentage distribution of respondents according to their
age

RELIGION:

The data presented in Table 1 and Figure 2 shows that, maximum subjects 49 (81.67)

were Hindus, whereas, 5 (8.33%) belong to Muslims. A small percentage (6.67%) of

subjects were Christian and the remaining 3% of the respondents were from other

religion.

28
 Figure 2: Frequency and percentage distribution of respondents according to their
religion

EDUCATION:

The data presented in Table1 and Figure 3 depicts that majority of the respondents
20 (33.33%) have not attended any form of formal education and 13 (21.67) of them
have studied further after the matriculation. Some of them, 13 (21.67%) of them have
studied only till primary school.

29
 Figure 3: Frequency and percentage distribution of respondents according to their
education

OCCUPATION

The data presented in Table 1 and Figure 4 shows that majority 26(43.33%) of the

respondents’ are house wives, 22 (36.67%) and 12(20%) of them were coolie workers and

employed people respectively.

30
Figure 4: Frequency and percentage distribution of respondents according to their
occupation

FAMILY INCOME (RUPEES PER MONTH)

Table 1 and Figure 5 show that 17(28.33%), of the respondents’ monthly income of the

family is below 5000. While 24 (40%) earn a monthly family income between 5001 and 10,000.

Only 19 (31.67%) person’s family monthly income is greater than 10,000.

31
Figure 5: Frequency and percentage distribution of respondents according to their
family income.

AGE AT MENARCHE

It is evident from Table 1 and Figure 6 that, majority 33 (55%) of the respondents

of them got achieved menarche at the age of 14 and few of the respondents, 9 (15%) got

achieved the age of 13.

32
Figure 6: Frequency and percentage distribution of respondents according to their
age of menarche.

AGE AT MARRIAGE

It is evident from Table 1 and Figure 7 that, majority 29 (48.33%) of the

respondents of them got married below the age of 20 and few of the respondents, 8

(13.33%) got married above the age of 25.

33
Figure 7: Frequency and percentage distribution of respondents according to their
age at Marriage.

NUMBER OF CHILDREN

From Table 1 and Figure 8 it reveals that, majority of the respondents, 36

(60%) have two children, and 8 (10%) of the subjects have single child, while the

number of subjects with three or more children were 14(23.33%).

34
Figure 8: Frequency and percentage distribution of respondents according to the
number of children.

FAMILY HISTORY OF CERVICAL CANCER

From Table 1 and figure 9, it is evident that 1 (1.67%) respondents has knowledge

family history of cervical cancer and the remaining 59 (98.33%) of them had no history

of cervical cancer.

35
Figure 9: Frequency and percentage distribution of respondents according to their
family history of cervical cancer.

KNOWLEDGE ABOUT CERVICAL CANCER

From Table 1 and figure 10, it is evident that 17 (28.33%) respondents have

knowledge about birth spacing and the remaining 43 (71.67%) of them had no knowledge

about birth spacing.

36
Figure 10: Frequency and percentage distribution of respondent’s according to
their knowledge about cervical cancer

SOURCE OF INFORMATION

Table 1 and figure 11, shows that, out of the 17 subjects with previous knowledge of

birth spacing, 8(47.05%) of them acquired knowledge through electronic media, while

family members informed 1 (5.88%) of them about the birth spacing and health

37
professional imparted the knowledge for another 3 (17.65%). Print media helped 4

(23.53%) subjects to know about birth spacing.

38
 Figure 11: Frequency and percentage distribution of respondent’s
according to source of information on cervical cancer

39
 SECTION 2:

KNOWLEDGE OF WOMEN REGARDING CERVICAL CANCER

Knowledge of women regarding cervical cancer were assessed through structured

knowledge interview schedule. The total knowledge score ranged from 0-17. The
knowledge scores further arbitrarily divided as poor knowledge (0-6), average knowledge
(7-11) and good knowledge (12-17)

Table 2

Frequency and percentage distribution of women according to their knowledge

regarding cervical cancer

Level of knowledge f %

poor 34 56.67%
average 24 40%
good 2 3.33%

It is evident from table 2 that majority of the women( 56.67%) had poor knowledge

regarding cervical cancer. Data also revealed that 3.33% women had good knowledge

regarding cervical cancer.

40
 SECTION 3:

PERCEIVED BARRIERS OF CERVICAL CANCER SCREENING

Perceived barriers of cervical cancer were assessed through structured interview check
list. The total barriers of cervical cancer screening include 15 in that the barrier which get
highest frequency and percent will be the highest barrier of cervical cancer screening.

Table 3

Frequency and percentage distribution of perceived barriers of cervical cancer

screening

Sl

no Items f %
1 I don’t know the interval of Pap smear screening test 48 80%
2 I don’t know when the suitable age for a Pap smear 56.67%

examination 34
3 It is unnecessary to go only for a Pap smear 13 21.67%
4 Pap smear test is too expensive 39 65%
5 I feel shy, embarrassed and reluctant during the Pap 57 95%

smear test examination

6 Pap Test make me worry 40 66.67%
7 Pap Test is painful 37 61.67%
8 Virginity will be taken away if pap test is done to the 51 85%

virgin woman
9 Do not know where to go for a Pap smear test 41 68.33%
10 Partner/ Family member does not allow you to do 53 88.33%

Pap smear test

11 None of the Health care providers advised you to do 44 73.33%

the test
12 I have never received Pap smear test results 12 20%

41
13 I feel hesitant to discuss with health care personnel 37 61.67%

on Pap smear screening test

14 Pap smear examination process will take a long time 34 56.67%
15 I’m afraid of the results may show positive for cancer 23 38.33%

It is evident from table 3 that most influencing barriers of cervical cancer screening is the

shy, embarrassed and reluctant during the Pap smear test(95%) and least barrier of

cervical cancer screening is the never received Pap smear test results (20%). Data also

revealed that( 88.33%) partner/ family member does not allow women to do Pap smear

test.

SECTION 5

Association of determinants influencing birth spacing with their selected personal variables

42
 To find out the association of cervical cancer screening among married women with their

selected personal variables, Chi square was computed and to test the statistical significance,

following null hypothesis is stated:

H02: There will be no significant association of knowledge of cervical cancer screening

among married women with their selected personal variables viz., age, religion,

education, occupation, family income, age at marriage, age at menarche, number of

children, and exposure to mass medias.

The findings are presented in Table 4.

TABLE 4

Chi-square values between birth spacing and with their selected personal variables

43
 n=200

Poor knowledge Average knowledge d(f) Chi square

Selected personal value
variables
1. Age (in years)
 19-28 10 2
 29-37 16 8 3 4.19
 38-46 10 5
 47-40 5 4
2. Religion
 Hindu 40 9
1 1.48
 Other than Hindu 8 3
3. Education
 No formal 15 5
education
 Primary 10 3 #9.14*
school education 3
 High school 8 5
education
 PUC and 8 6
above
4. Occupation
 House wife 20 6
1 11.88*
 Employee 22 12

44
5. Family income per
month
.636
 ≤5000 13 4 2
 5001-10000 20 4
12 7
 >10000
6. Age at menarche
 13 5 4
 14 21 12 2
 15 12 6 4.33
7. Age at marriage
 Below 20
years 20 9
.018
 21-25 years 1
And Above 25 25 6
years
8 . Number of
children
 One 7 2
25 11 2 12.37
 Two
10 6
 Three and
above

9. Knowledge about
cervical cancer
 Yes 10 7
1 2.86
 No 30 13
Source of
information
 Electronic 6 2 2 #16.36*
media 7 2
 others
 (1) = 3.84,  2 (2) = 5.99,  2 (3) = 7.82,  2 (4) = 9.49, p <0.05, * = Significant
2

# = Yates Correction

45
 The data presented in the Table 5 shows that, the computed Chi-square value for association of

knowledge of cervical cancer screening among married mothers with their selected personal

variables is found to be statistically not significant at 0.05 levels of significance except for

mothers education and occupation, and source of information having significant association with

birth spacing at 0.05 level of significance. Hence, the findings partially support the null

hypothesis H02 and the research hypothesis, inferring that determinants influencing birth spacing

among married women are partially influenced by their selected personal variables.

46
 CONCLUSION

The main aim of the study was to assess the knowledge and perceived barriers of cervical cancer

screening among married women. Data was collected from 60 women who are in the age group

between 19 to 55 and conceived minimum two times and residing in a selected areas of Mysore.

The findings of the study revealed that, majority of the women( 56.67%) had poor

knowledge regarding cervical cancer. Data also revealed that 3.33% women had good

knowledge regarding cervical cancer. It was also evident that there was no significant

association exists on determinants influencing birth spacing among mothers except for mother’s

education and occupation, and source of information with their selected personal variables.

47
IMPLICATIONS

The findings of the present study have implications for nursing practice, nursing

education, nursing administration and nursing research.

Nursing Practice

The findings of the study revealed that, women had less knowledge regarding

cervical cancer. Nurses can play a pivotal role in organizing and executing creative

awareness programmes for all vulnerable sections of society to improve knowledge,

develop positive attitude and increase the practices of cervical cancer screening test to

detect cervical cancer at early stages and decrease mortality related to cervical cancer.

Creative educational programmes and cervical cancer screening camps can be planned

and organized for the women. Every health professional should educate and motivate

women for these practices.

Nursing Education

Education is a key component to update and improve the knowledge of an

individual. The nursing students should be taught regarding incidence, signs and

symptoms, early detection methods of cervical cancer and demonstrated pap smear

collection procedure during their training so that they can utilize the knowledge in their

daily professional practice

48
 Also nursing students should be provided with learning experiences in planning

and organizing health education programmes on breast cancer screening tests in

institutional and community setting.

Nursing Administration:

Continuing education is an essential process, it enables the learner to keep abreast

of changes and development in her/his field of specialty. Nurse administrators are the key

persons to plan, organize and conduct in-service education programme to nursing

personnel. Continuing nursing education programs can be planned and conducted to the

nursing staff regarding the importance of breast cancer screening tests in early detection

of breast cancer and reducing mortality related to breast cancer. Nurse administrators can

plan and organize scheduled breast cancer screening programs for the women in

institutional and community setting. Nurse administrators and leaders should influence

the policy makers to include routine cervical cancer screening camps and programs to the

existing health programs.

Nursing Research

The prevalence and incidence of cervical cancer and its complications on health

are high in the present days. This study has attempted to bring out facts related to the

knowledge regarding cervical cancer and perceived barriers of cervical cancer screening

among women. Further research can be undertaken to study the various factors that

influence the practice of regular cervical cancer screening tests. The results of the study

49
also laid further emphasize on early screening strategies to reduce complications of

cervical cancer and thereby mortality of women related to cervical cancer.

LIMITATIONS

The limitations of the present study were:

1. This study adopted non probability non probability purposive sampling; hence the

generalization of the findings outside the study sample is limited.

2. The sample size was limited only to sixty women. Hence it cannot be generalized

to large population.

3. Sample of respondents was selected only from Bamboo bazar UHC. Hence, this

limits the generalization of findings

4. Data collection was through a structured interview schedule.

50
RECOMMENDATIONS

Keeping in view the findings of the present study, the following recommendations

were made:

1. A large scale study can be conducted to generalize the findings

2. A similar study can be conducted in the rural settings to find out the knowledge,

attitude and practices of rural women regarding cervical cancer screening.

3. A comparative study can be conducted between rural and urban women by using

same instruments to generalize the findings.

4. An explorative and comparative study can be conducted among working women

and home makers.

5. Adequate educational program and screening program should be organized in

institutional and community settings.

6. Health professionals, especially community health nurse should conduct regular

health checkups and screening program for cervical cancer.

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Regional Office for South-East Asia. New Delhi. 1998.

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Annual Report. Mumbai India; 1999.

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SEER Publication November 2010

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2008, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10.

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6. Progress in Cervical Cancer Prevention: The CCA Report Card South Africa

AUGUST 2011

7. Human Papillomavirus and Related Cancers in India, WHO/ICO Information

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8. Nandakumar A, Ramnath T, Chaturvedi M. The magnitude of cancer cervix in

India. Indian Journal of Medical Research.2009 Sep; 130:219-228.

9. Pitts M, Clarket T. Women’s knowledge of cervical cancer. Health education

Research. 2002 December; 17(6): 706-14.

10. Asquith C, McCaffery K. Social and Psychological Impact of HPV in Cervical

Screening. University of Sydney.2005 Oct;133-142

11. Hariharan V. Knowledge and Practice regarding Cervical Cancer among Married

Women. Indian Journal of Nursing Studies. June 2011; vol2(1)

12. Tbeu PM, Major AL, Rapiti E, Petignat P, Bouchardy C, Sando Z, et al. The

attitude and knowledge of cervical cancer by Cameroonian women; a clinical

survey conducted in Maroua, the capital of Far North Province of Cameroon.

International Journal of Gynecological cancer, 2008 Jul; 18(4):761-765.

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13. Rezaei, Baradaran M. Effects of 2 Educational Methods on the Knowledge,

Attitude, and Practice of Women High School Teachers in Prevention of Cervical

Cancer.Cancer Nursing;Sept-Oct 2004:vol(27)5-p 364-369

14. Ali SF, Ayub S, Manzoor NF, Azim S, Afif M. 2010 Knowledge and Awareness

about Cervical Cancer and Its Prevention amongst Interns and Nursing Staff in

Tertiary Care Hospitals in Karachi, Pakistan. PLoS ONE 5(6): e11059.

doi:10.1371/journal.pone.0011059

15. John. Effectiveness of two self- instructional modules on knowledge of women

regarding cervical cancer. Cancer Journal, 1993.

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control of carcinoma cervix in India: Hospital based cytological screening

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Centre). Human Papillomavirus and Related Cancers in Botswana. Summary

Report 2010. [Date accessed]. Available at www. Who. int/ hpvcentre.

18. Donders GGG. Change in knowledge of women about cervix cancer, human

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186(5):938-43.

SECTION –A

Profoma For Personal Variables

Instructions:

Dear participant,

54
This questionnaire is related to the demographic variables. I am here with requesting you

to answer all the questions. This information will be treated as confidential. Kindly write

down the appropriate information or tick (√) mark for the most appropriate answer in the

box given on the right side of each item.

Code

1. Age in years.

2. Religion

a) Hindu ( )

b) Muslim ( )

c) Christian ( )

d) Any other ( )

3. Education

a) No formal education ( )

b) Primary school education ( )

c) High school education ( )

d) PUC and above ( )

4. Occupation

55
 a) House wife ( )

b) Coolie ( )

c) Employee ( )

d) Business ( )

5. Family income per month

a) Below RS 5000 ( )

b) RS 5001- RS10000 ( )

c) Above RS10000 ( )

6. Age at menarche

7. Age at marriage

a) Below 20 years ( )

b) 21-25 years ( )

c) Above 25 years ( )

8. Number of children

a) One ( )

b) Two ( )

c) Three and above ( )

56
 d) No children ( )

9. Family history of cervical cancer

a) Yes

b) No

10.Do you know about cervical cancer.

a) Yes

b) No

If Yes

Source of information about birth spacing

a) Electronics media ( )

b) Family members ( )

c) Friends ( )

d) Health personal ( )

e) Print materials ( )

57
58